HomeMy WebLinkAboutApplicationRECEIVED
t:
GARFIELD COUNTY
COMMUNITY DEVFLOPMENf
195 W. 14th Street
Rifle, CO 81650
(e70) 62s-s200
Pu,blic Heultlt
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Sprlngs, CO 81601
(e70) s4s-6614
Gørfield Couny
n New lnstallation
I Transient Use
TYPE OF
NG USAGE TYPE
ir
B
E Alteration
tr Non-DomesticComm./lndustrialDwelli
n other Descrlbe
rNvowED P¡F.I|E$ ..
t¿+Y\!J t7¡A "ryt5Property
Malllng Address
Emall Address¡
Í,.)uMailing Address:
EmallAddress:
PROJECT LOCATION AND DESCRIPnON
_Phone:
Mailing Address
EmallAddress:
Stream or Creek
Job Address:
Assessor's Parcel -u1
Buildlng or Servlce
Distance to Nearest Commun¡tY Sewer System:
ì Was an effort made to connect to the Community Sewer System:
t4
Potable Water Source
& Type
tr Well tr Sprlng ClBtern
Commun¡ty Wãter System Name
Garfield County Public Health Department-working to pronrote health and prevent disease
Aoolicant acknowledges that the completeness of the application isconditionalupon such further'"iíti¿Jtä-.üãñd åijãitññtitàsti and rdpons as may be r'ei¡uired by the local health department to be
ffiË;;å'f;;ìriùî Ëy rh" ãpijlicañt or by the locál.health depart'ment for.purpose of the evaluation of
iËËäËìl¿;ti;.|;Àd ilíe ¡ssuårice of the pärmit ls su.bject to stich terms and conditions as deemed
neceisarv to iniure compliance with rulés and regulaiions made, informatíon and,reports submitted
iìã;;iliiñ'r;ïlããi¡irá¿ tð ul lubmitted by the apÞlicant are or will be rep.resented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the.local
¡ä"-rùìili ıihìanh in'evaluatin!'the same for purposes of issuing the. permit applie.d for herein' I
fuither understand that any falsification or misrepresentation may result in the denial ot the
åpdiËåti"ñóiievocãtion of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certiflcatlon above as
well as have provided the requ¡red informatlon which ls correct and accurate to the best of
my knowledge.
{/ùH EWNò
Property Owner Print and Sign
5 l7
Date
l\Ll
Speclal Condltlons:
Fees Paid:
l?5,¡oTotal Fees¡
175. øPerm¡t Fee:
l?s.gg
Belaíce Duel+dlssue Date:
etf/t #/zo z rOWTS Permlt:
sGPl- 68{9
Bulldlng Permlt
/*FI
Slgned Approval
Garlleld County Publlc Health O€partmentl /tTt/tt/¿'¿¿:¿1'
Date
i'.r':. ;
t ¡t,l,r', t l